Take Control of Your Care
 
 

Take Charge by Getting All the Information You Can

Shop for Services With Our Treatment Cost Estimator and Provider Search Tool

Available through the member portal—so it can tailor results based on your specific plan—our treatment cost estimator and provider search tool lets you shop for affordable, quality health care just like you would for anything else. And it lets you know what to expect before your visit.

It’s the only tool that determines the services, timelines, and costs for a complete treatment of care—from diagnosis through follow-up. It even shows the medications you’ll need.

Log onto our member portal to get started.

Digital Tools You Can Use

With a suite of digital tools that help you make smarter health care decisions and give you the information you want, when you want it. Start taking advantage of these tools today to save time and money!

  • Telehealth, powered by Teledoc* - 24/7 access to a doctor through the convenience of phone, video, or mobile app visits.
  • MyWire* - Receive important, personalized health communications, such as reminders for annual doctor’s visits and screenings, tips for saving money on your care, member discounts and more.
  • Tufts Health Plan Mobile App - We’ve taken the top four things members want to do online and put them into our mobile app. Now you can do them quicker and easier than ever.

*Ask your employer if your plan benefits include Telehealth and MyWire.

We Are Here to Help You

​Special Programs for New Moms and Moms-to-Be

  • Maternity Care - once your baby (or babies!) arrives, you could be eligible for post-delivery support and services. This may include a home visit so we can make sure everything is fine and answer any questions you might have.
  • Healthy Birthday - for moms who are at risk for preterm labor, or have complex medical conditions through pregnancy and delivery. One of our obstetrical nurse care managers can provide support to help you have a positive transition to home.
  • Tufts Health Priority Newborn Care Program - a specialty nurse care manager provides family-centered support for parents of new babies born with complex medical needs, across all care settings and at home.

​Talk to a Nurse 24/7

Have a medical concern and not sure what to do? Just call Nurse 24 at 866-201-7919 for immediate and reliable health advice and information. Registered nurses are available 24 hours a day, 7 days a week to answer any of your health questions, including concerns about:

  • Symptoms you are experiencing
  • Minor illnesses and injuries
  • Chronic conditions
  • Medical tests and medications
  • Preventive care
  • Doctor visit preparation

Do You Have a Chronic Condition? Nurse Care Managers are Here for You.

Members with a severe illness or an ongoing chronic condition like diabetes or asthma may be able to get valuable help by working with a nurse in our Chronic Care Management programs.

The goal of care management is to help you manage your health interests and goals, and implement your doctor’s plan of care. Depending on your condition, a nurse care manager will work with you on specific actions to offer the best opportunity for improved health and cost reduction. The nurse care manager will also help you learn about online resources, social services, pharmacy services, and other resources to support your health.

Participation is completely voluntary and has no effect on your health care coverage. If you would like more information about programs to help you manage your health, please call Tufts Health Plan Member Services at the number on your member ID card.

Priority Care for Members with Complex Conditions

The Tufts Health Priority Care program can support the care prescribed by your doctor. This voluntary program is designed for members with complex medical needs (e.g. cancer, stroke, MS) and is available at no additional cost. Members who wish to enroll may self-refer to the program by calling 888-880-8699, ext. 53532. A member’s in-network physician can also directly refer them to the program by calling 888-766-9818, ext. 53532.

A Tufts Health Plan nurse care manager may contact a member to discuss his or her needs and interest in the program. Members are identified by a predictive modeling algorithms based on claims data and program criteria.

Get the Preventive Care You Need: Talk to your doctor about the routine health screenings and immunizations that you should have. Designed to keep you healthy, preventive care is covered 100%.

Take Time for Yourself

Behavioral Health

Our holistic approach to your health involves the deep integration of medical and behavioral health programs. We’re managing the whole person to achieve better results. Although behavioral health care is often overlooked by individuals and their families, we encourage you to take advantage of your benefits if and when you need them.

We provide a wide range of behavioral health benefits and support, including:

  • Inpatient access to behavioral health and substance use disorder services
  • Outpatient behavioral health and substance use disorder benefits
  • Help with understanding addiction and available treatment options
  • Applied Behavioral Analysis (ABA) services for Autism Spectrum Disorders

The Right Care in the Right Treatment Setting

Our Utilization Management Program

We want you to have the care you need to stay healthy. However, we also want to make sure services aren’t overused or used inappropriately, which drives up costs for everyone.

That’s the idea behind our Utilization Management (UM) program: to help you receive quality health care in an appropriate treatment setting. Through this program, we make coverage decisions about care based on careful evaluation of available clinical information.

We Know Health Care Can Be Complicated

UM evaluates requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) to determine the medical necessity and appropriateness of the health care services under your benefit plan. These guidelines include the following:

  • Prospective (Before Treatment): We determine whether a treatment is medically necessary before it begins.
  • Concurrent (During Treatment): We review treatment during the course of care to determine medical necessity.
  • Retrospective (After Treatment): We review treatment for medically necessity after treatment is complete.

For services and prescriptions that require preauthorization, we conduct pre-service reviews. If you are hospitalized, we review all available information to help provide a smooth transition from hospital to home, or from hospital to another health care environment. Reviews are also conducted post-service to review prescriptions and other medical needs.

Who makes utilization management decisions?

For medical coverage decisions, denials are made only by board-certified physicians.

For pharmacy coverage decisions, denials are made only by board-certified physicians or registered pharmacists.